President Obama signed into law on July 22, 2010 the Improper payment Eliminaton and Recovery Act. in signing the bill, the President said overpayments amount to $100 billion representing more than the combined budgets of the Depts. of Eduction and the Small Business Administration. The President also announced the existence of a " no pay" list of entities that are ineligible to receive payments.

The  law amends the Improper Payments Infomation Act of 2002 to expand requirements for identifying programs and activities susceptible to improper payments. This law requires each federal agency during the year after the enactment of this act, to review and identify agency programs and activities that maybe susceptible to significant improper payments.

CG,I the RAC for Region B, has followed in Connolly's footsteps and added the CMS approved issue of Review of Inpatient Admission Orders.  CGI has also aded 88 more DRG validation issues. Please ceck their website for more detail.

Connolly Healthcare, the RAC for Region C, has added 6 issues for outpatient hospital and 12 issues for non-medical necessity DRG validation reviews for providers in Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia (WPS only)

Health Data Insights the RAC for Region D added 4 new RAC issues for claims review to its CMS approved list. This affects all providers in region D states. Please refer to their websit for details.

Connolly Healthcare has added 25 RAC issues for non-medical necessity DRG validation reviews review to its CMS-approved list this week for providers in Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only) and West Virginia (WPS only).

Please refer to their website for more detail

April 28, 2010 from 1-2:30 PM National RAC 101 Call. No pre-registration. Call-in number 1-877-251-0301

May 12, 2010 RAC call for physicians from 1-2:30 PM. Call-in number 1-877-251-0301    

CMS will not evaluate or enforce the "direct supervision" requirement for therapeutic services furnished in calendar year 2010 to outpatients in critical access hospitals according to a March 15, 2010 agency notice to Congress.

This has been a concern for some rural hospitals that do not have the medical staff available to provide 24/7 level of supervision. 

Hello Everyone

Please check your respective RAC websites for updates on new CMS approved issues 

Connolly Healthcare, the RAC for Region C, has posted 19 new approved issues for Complex Review on their RAC Issues page.

The new issues were posted on Monday, February 8, 2010. The listed issues include only single MS-DRGs, but are still not listed in any discernable order. All of the new issues are approved for Complex Review in all thirteen of the Region C states (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX), using DRG Validation techniques, as outlined in the Medicare Program Integrity Manual, Chapter 6.5.3.

CMS has modified the additional documentation request limits for the RAC program in FY2010 for institutional providers. These limits will be set by each RAC (CMS) on an annual basis to establish a cap per campus on the maximum number of medical records that maybe requested per 45 day period. 

The update was posted on the CMS website on Friday January 28th. Previously the rule applied to ADRs for DRG validation issues only, as posted on the CMS website in December 2009.

Limits will be based on the servicing providers/supplier's Tax Identification Number and the first three positions of the zip code where they are physically located. Limits will be set at 1% of all claims submitted for the previous calendar year divided into eight periods (45 days). A providers limit will be applied across all claim types including professional services. In addition, in FY 2010 CMS will allow the RAC's to request permission to exceed the cap. Permission to exceed the cap cannot be requested in the first 6 months of the fiscal year. The RAC's must be request approval from CMS on a case by case basis and affected providers will be notified prior to receiving additional requests.   

Has anyone received demand letters related to the automated reviews? If so, what are the RAC's denying? 

CGI Federal the RAC for Region B has posted new issues on their website. Please refer to their website http:// racb.cgi.com for more information.

Connolly the RAC for region C has posted new issues on their web-site approved by CMS. Currently Connolly has 76 issue they are looking at for overpayments.

Please refer to te Connoly RAC website for details. www.connollyhealthcare.com/RAC/pages/approved_issues.aspx

New issues for HDI are as follows:

1. Skilled Nursing Facility (SNF) Consolidated Billing. Payment for the majority of SNFservices provided to beneficiaries in a Medicare covered Part A SNF stay are included in a bundled prospective payment made through the FI to the SNF. These bundled services are to be billed by the SNF to the FI/A/B/MAC in a consolidated bill. The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part SNF stay and PT,OT,ST services received during a non-covered stay.

2. 4221 Excessive Units. The description of the procedure code A4221 is "supplies for maintenance of drug infusion catheter per week" The overpayment is anything paid over once a week.

3. Prosthetic Bundling: When prosthetics are provided, prosthetic solutions  and or additions of procedures and components are covered in accordance with the functional level assessment, except for certain identified codes cited which will be denied as not medically necessary.

4. Prosthetic additions with initial or preparatory knee prosthesis. When an initial below the knee prosthesis (L5500) or preparatory  below the knee  prosthesis (L5510,L5530,L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in  accordance with the functional level assessment, except for certain codes. Therefore, an issue may exist when these codes are billed and reimbursed under Medicare part B with such a prosthesis.

5. Lower Limb Suction Value Prosthesis. Codes L5647 and L 5652 incorporates a suction valve in its design, therefore, separate payment is not allowed for code L 5671, which was created to specifically to address suspension sockets using mechanical locking mechanisms. This code was not meant to be an "add-on" for suction suspension. Therefore, an issue may exist when such a locking mechanism is billed and reimbursed under Medicare Part B along with a suction valve suspension.

6. Solid insert with seat or back wheelchair cushions: Code E0992 (solid seat insert) is not separately payable when provided with a seat or seat back wheelchair cushion. Therefore, an issue may exist when E0992 is billed and reimbursed under Medicare Part B with a set or seat back wheelchair cushion. 

DCS has added six new issues for DME claims review in all states in the region:

1. Wheel attachment with new non-wheeled walker: Wheel attachment (E0155) cannot be paid on the same day or within one month of the initial issue of a non-wheeled walker. Therefore, an issue may exist when a beneficiary receives this wheel attachment, which has been billed and reimbursed under Medicar Part B within a month of an initial issue of a non-wheeled walker.

2. Headrest with a power operated vechicle or a power wheelchair with a captain's Chair seat. Headreats (E)955) may not be billed the same date of service as a Power Operated Vechile or Power Wheelchair with a captain's chair seat. Therefore, an issue may exist when a beneficiary receives a POV or PWC with a captain's chair seat.. and a headrest ,which has been billed and reimbursed under Medicare Part B on the same date of service and for the same beneficiary.

3. Multiple DME rentals within a month. Certain pocedure codes may not be billed in conjunction with other procedure codes for the same date of service and for the same beneficiary. Therefore, an issue may exist when these codes are billed and reimbursed under Medicare Part B on the same date of service and for the same beneficiary.

The OIG has issued a review of CareAlliance a Comprehensive Outpatient Rehab Facility (CORF) on November 18, 2009. They were investigated to see whether or not claims submitted fo PT,OT,ST were in accordance with Medicare reimbursement guidelines.

Outcome: Care Alliance  in Florida received approximately 1.7 million for therapy services that did not meet the Medicare reimbursement requirements for calendar year 2003.

812 services did not meet for reporting service units

240 services did not meet for documentation requirements

104 services did not comply with the wriitten plan of treatment

30 services were not medically necessary  

For more information please refer to the OIG report found on www.oig.hhs.gov

CMS has just modified the limits it set in October 2008 for the number of records that can be requested every 45 days. These limits will be set by ech RAC (CMS) on an annual basis to establish a cap per campus on the maximum number of medical records that maybe requested per 45 day period. A campus unit may consist of one or more seperate facilities/ practices under a single organizational umbrella. Each limit will be based on that unit's prior fiscal year Medicare claims volume.

Two caps will exist in FY 2010. Through March 2010, the cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers. However, from April through September 2010, providers/suppliers who bill in excess of 100,000 calims to Medicare will have a cap of 300 additional documentation requests per campus unit, per 45 days.

In addition, in FY 2010 CMS will allow the RACs to request permission to exceeed the cap.  

To read more about the new update on RAC please go to the cms website www.cms.gov/RAC